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Please print or 1 Form OnWried for use on elite(12-0tch)t 00/7 F1135— SC pPW 1011012017 Form Approved.OMB No.205D-0039 <br /> UNIFORM IiA7ARp0US 1'Generator In Number 2.Page 1 d 3 Ere Res se Phone FNenf t T`acMng NumWASTEMANIFEST CAL000359102 1 Ir 2031�s Tis14. <br /> FLE <br /> &BVW" Gamatcr' Address M different then mailing addma) <br /> 252.6 W.WaShingttOn Street <br /> Stockton-CA 952.03 Stol�ton,GA 95203 <br /> gawraws Ptwne:(2091320-3714 ATMAesse Lewis <br /> 6. F U.S.EPA ID Number <br /> 7.Transporter 2 CoMparry Noftia U,S,EPA 10 Number <br /> 8.Designated Facility Name and SiteAddress U.S.EPA ID Number <br /> 500 West Lo ern�Roa�ow LLG <br /> Buttonwillow.(;A 93206 4A D 9 V06 75'Z 7� <br /> Faali s Phone, (6611762-6200 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, f0.Containers 11.Total 12.Unit <br /> HM and PaddM Group(if any)) 13.Waste Codes <br /> No. Type Quantity WtNcf, <br /> f NON-RCRA HAZARDOUS WASTE.SOLIDS,(FLY ASH) 573 <br /> hT `f�46c� Jo _ _ .1.. . <br /> W 2 <br /> 3. I <br /> 4. 4 <br /> 14:Specie 4ndl®al2jWC 1.and Additional Information <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are N all respeds in proper condition for 7armsport according to applicable international and nallowl governmental regulalfons.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent, <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantity generetw)is true, <br /> "n7AslrintWTypod Namecure ear <br /> 7V- <br /> .—a�OYOW r , ' <br /> J 16.International Shipmerills <br /> Q Import to U.S. 1:1 Dport ham U.S. Po en fa>aL�_{�_�....__.._._...__._.--.-_.__-- <br /> rE Tramrtar signature for eXpoft only): Date 12tN U.S.: <br /> rY 17.TransportarAcknowledgmenl of Reoetpt of Materials <br /> ransPorler 1 NnbgrypDd Name sie y oar <br /> Transporter EedfTmom, ear <br /> 18.Discrepancy r� <br /> 18a.Discrepancy indication Space Quantity 1:1 Type ❑Residue Partial Rejection lJ Full Rejection <br /> Mardfest Raference Number. <br /> 16b,Alternate Facility(or Gisneratm) U-S.EPA ID Nurnbef <br /> V <br /> Q <br /> u FarlAt s PFhgna: <br /> W ZSignatureofAlWnaleFad*tor Generator) Month pay Yopr <br /> Q <br /> 19.Hazardous Waste FReport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3- 4 <br /> H132 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> Pramtedryped Na` SOV11 m WWII Day Year <br /> EPA Form 8700.22(Rev. W5) Previous aditjcns am obsolete. DESIGNII�E.D FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Clean Marbers has the appropriate permits for and will accept the waste the eneratof 1s SOfPpIng. ► <br /> I <br />